Provider Demographics
NPI:1255485165
Name:GERTSBERG, YULY (DDS)
Entity Type:Individual
Prefix:
First Name:YULY
Middle Name:
Last Name:GERTSBERG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 E 13TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-1920
Mailing Address - Country:US
Mailing Address - Phone:718-998-2929
Mailing Address - Fax:718-998-1056
Practice Address - Street 1:1720 E 13TH ST STE 1
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1920
Practice Address - Country:US
Practice Address - Phone:718-998-2929
Practice Address - Fax:718-998-1056
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0450561223S0112X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01759237Medicaid
NYD29051Medicare ID - Type Unspecified
NY01759237Medicaid